# NTSB GAA17CA017: Piper PA 17, N4584H, Keene Valley, NY, October 6, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: October 6, 2016, 16:40 local (20:40 UTC) - Place: Keene Valley, NY - Coordinates: 44.221111, -73.787498 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.2211&lon=-73.7875&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 15, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 94190 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA17CA017 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94190/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94190 - Page: https://openairdocs.org/ntsb/GAA17CA017 ## Probable cause The pilot's failure to use the proper hand propping procedures, resulting in a runaway airplane and an impact with trees. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-17, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7101702), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-17, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7101702), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Not installed/available; cases with it: [Piper PA-17, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=7101702), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Effect on equipment; cases with it: [Piper PA-17, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7101702), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event); cases with it: [Piper PA-17, 1 case](https://openairdocs.org/ntsb-events/200/sequence.md?model=7101702), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis The pilot reported that he attempted to hand prop the unoccupied and unchocked airplane, but was unsuccessful. He returned to the cockpit to prime the engine, but then decided to instruct his passenger on how to enter and exit the cockpit, which she then practiced multiple times before exiting the airplane to watch the start procedures again. The pilot further reported that he attempted to hand prop the airplane a second time and the engine started and accelerated to a high revolution per minute (RPM) setting. The pilot was unable to restrain the airplane by holding the right wing lift strut and the airplane made a right circle, entered a wooded area, and impacted trees. The airplane sustained substantial damage to the wings and fuselage. The pilot later reported that the airplane was not equipped with a parking brake. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. Federal Aviation Administration's Airplane Flying Handbook, FAA-H-8083-3A, contains a section titled "Hand Propping" which states: An engine should not be hand propped unless two people, both familiar with the airplane and hand propping techniques, are available to perform the procedure. The person pulling the propeller blades through directs all activity and is in charge of the procedure. The other person, thoroughly familiar with the controls, must be seated in the airplane with the brakes set. As an additional precaution, chocks may be placed in front of the main wheels. If this is not feasible, the airplane's tail may be securely tied. Never allow a person unfamiliar with the controls to occupy the pilot's seat when hand propping. The procedure should never be attempted alone. ## Factual narrative The pilot reported that he attempted to hand prop the unoccupied and unchocked airplane, but was unsuccessful. He returned to the cockpit to prime the engine, but then decided to instruct his passenger on how to enter and exit the cockpit, which she then practiced multiple times before exiting the airplane to watch the start procedures again. The pilot further reported that he attempted to hand prop the airplane a second time and the engine started and accelerated to a high revolution per minute (RPM) setting. The pilot was unable to restrain the airplane by holding the right wing lift strut and the airplane made a right circle, entered a wooded area, and impacted trees. The airplane sustained substantial damage to the wings and fuselage. The pilot later reported that the airplane was not equipped with a parking brake. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. Federal Aviation Administration's Airplane Flying Handbook, FAA-H-8083-3A, contains a section titled "Hand Propping" which states: An engine should not be hand propped unless two people, both familiar with the airplane and hand propping techniques, are available to perform the procedure. The person pulling the propeller blades through directs all activity and is in charge of the procedure. The other person, thoroughly familiar with the controls, must be seated in the airplane with the brakes set. As an additional precaution, chocks may be placed in front of the main wheels. If this is not feasible, the airplane's tail may be securely tied. Never allow a person unfamiliar with the controls to occupy the pilot's seat when hand propping. The procedure should never be attempted alone. ## Aircraft - Registration: [N4584H](https://openairdocs.org/aircraft/N4584H), registered now, S/N 17-9, built 1948 (OpenAirDocs) - Reported make and model: PIPER PA 17 (NO SERIES) - Registry model: [Piper PA-17](https://openairdocs.org/model/piper-pa-17) (registry code 7101702) (OpenAirDocs) - Registry engine: [Continental A&C65 series](https://openairdocs.org/engine/continental-a-c65-series) (registry code 17003, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17-9 - Year built: 1948 - Airframe hours: 2195.2 - Engines: CONT MOTOR A-65-8 65 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 1, 2016 - Departed: NY1, GHENT, NY - Destination: 1I1, Keene Valley, NY - Airport: 1I1, Marcy Field - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: none; airline transport, flight engineer; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review October 3, 2016; seat: none; restraint: none; flight hours: 8,964.5 total, 5.3 in this make and model, 5,094.1 as pilot in command, 5.3 in the last 90 days, 5.3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Temperature: 36 °F, dew point 34 °F - Altimeter: 30.27 inHg - Observed at: KSLK, 21 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20161006019899A](https://openairdocs.org/incident/20161006019899A), Oct 6, 2016: Piper PA-17, Keene, NY, Substantial damage. On 10/07/2016 the albany FSDO was contacted about an incident involving a Piper PA-17 vagabond aircraft. The aircraft had landed at Marcy Field (1I1)in Keene,… ## Other investigations on N4584H (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB NYC65F0094](https://openairdocs.org/ntsb/NYC65F0094), Mar 21, 1965: Piper PA-17 (N4584H), Laytonsville, MD, substantial damage ## Docket (2 files) The files NTSB released with the investigation on November 28, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94190. 1.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446781&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photo (Courtesy of FAA) (item 2, .PDF, 1 photo, 654 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446782&FileExtension=.PDF&FileName=Accident%20Photo%20(Courtesy%20of%20FAA)-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.